National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009

Identification of device-associated infections utilizing administrative data

BACKGROUND

Health care-associated infections are a cause of significant morbidity and mortality in US hospitals. Recent changes have broadened the scope of health care-associated infections surveillance data to use in public reporting and of administrative data for determining Medicare reimbursement adjustments for hospital-acquired conditions.

METHODS

Infection surveillance results for catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia were compared with infections identified by hospital administrative data. The sensitivity and specificity of administrative data were calculated, with surveillance data considered the gold standard.

RESULTS

The sensitivity of administrative data diagnosis codes for CAUTI, CLABSI, and ventilator-associated pneumonia were 0%, 21%, and 25%, respectively. The incorporation of additional diagnosis codes in definitions increased the sensitivity of administrative data somewhat with little decrease in specificity. Positive predictive values for definitions corresponding to Centers for Medicare and Medicaid services-defined hospital-acquired conditions were 0% for CAUTI and 41% for CLABSI.

CONCLUSIONS

Although infection surveillance methods and administrative data are widely used as tools to identify health care-associated infections, in our study administrative data failed to identify the same infections that were detected by surveillance. Hospitals, already incentivized by the use of performance measures to improve the quality of patient care, should also recognize the need for ongoing scrutiny of appropriate quality measures.

Creating a physician-led quality imperative

To emerge from a significant quality crisis, hospital administration recognized the need for physician leadership to drive improvements. A framework is presented for a physician-led Quality Summit to select best practice initiatives for implementation over 1 year. Results demonstrated statistically significant reductions in ventilator-associated pneumonia, decreasing from the first quarter 2009 baseline of 8.34 per 1000 ventilator days to 3.32 per 1000 ventilator days in second quarter 2010 (P = .0055). During the same time frame, catheter-associated urinary tract infections decreased from 4.35 per 1000 catheter days to 0.98 per 1000 catheter days (P = .0438), and severe sepsis/septic shock mortality declined from 33% to 13% (P = .0084). The customized World Health Organization Surgical Safety Checklist was used in 93% of surgeries within 1 month of adoption. Venous thromboembolism screening for adults became routine. The annual Quality Summit cycle engages physicians to introduce and spread quality improvement.

Assessing the necessity of the standardized infection ratio for reporting central line-associated bloodstream infections

This brief article presents results that support the contention that risk adjustment via the standardized infection ratio (SIR) for the reporting of central line-associated bloodstream infections (CLABSIs) may be no more predictive than standard rate adjustments utilizing CLABSIs per central line days (i.e., CLABSI rates). Recent data posted on the U.S. Department of Health and Human Services’ Hospital Compare website showed that nearly 70% of 1721 reporting hospitals with at least 1000 central line days had five or fewer infections during 2011. These hospitals had 39.3% of the total central line days and a significantly lower SIR than poorer performing hospitals with six or more CLABSIs (p<0.0001). In addition, 19 hospitals are presented which had central line days between 9000 to over 22,000 that also had zero to three CLABSIs. Some of these hospitals were university referral centers and inner city facilities. There was great variation of CLABSI cases among US hospitals. Evidence is mounting that all hospitals should be able to achieve a near zero incidence of CLABSIs and that these infections may in fact be near ‘never events’, which begs whether risk adjustment with the SIR is needed and whether it adds more information than does rate adjustment using CLABSI rates.

[Healthcare-associated infection rates: measuring and comparing. Experiences from the German National Nosocomial Infection Surveillance System (KISS) and from other surveillance systems]

Surveillance of nosocomial infections is meanwhile a cornerstone of infection prevention activities in hospitals. The objective of this article is to compare healthcare-associated infection rates in intensive care patients, neonatal intensive care patients and operated patients (ICU-KISS, OP-KISS, NEO-KISS) of the German nosocomial infection surveillance system (KISS) with the corresponding data of the US American National Healthcare Safety Network (NHSN) and the European Centre for Disease Prevention and Control (ECDC). In general, the methodological differences among the three surveillance systems are minor but there are some exceptions. Therefore, differences between countries have to be interpreted very carefully as they may be due to differences in diagnostics, patient mix, types of interventions, length of stay, selection of participating hospitals, post-discharge surveillance activities and interpretation of case definitions. Organizational aspects, such as mandatory participation with public disclosure on infection rates may also have an impact.

Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy

OBJECT

Many studies that have evaluated surgical site infections (SSIs) after craniotomy or craniectomy (CRANI) did not use robust methods to assess risk factors for SSIs or outcomes associated with SSIs. The authors conducted the current study to identify risk factors for SSIs after CRANI procedures and to evaluate outcomes attributed to SSIs.

METHODS

The authors performed a nested case-control study of patients undergoing CRANI procedures between 2006 and 2010 at the University of Iowa Hospitals and Clinics. They identified 104 patients with SSIs and selected 312 controls. They collected data from medical records and used multivariate analyses to identify risk factors and outcomes associated with SSIs.

RESULTS

Thirty-two percent of SSIs were caused by Staphylococcus aureus, 88% were deep incisional or organ space infections, and 70% were identified after discharge. Preoperative length of stay (LOS) ≥ 1 day was the only significant patient-related factor in the preoperative model (OR 2.1 [95% CI 1.2-3.4]) and in the overall model (OR 1.9 [95% CI 1.1-3.3]). Procedure-related risk factors that were significant in the overall model included Gliadel wafer use (OR 6.7 [95% CI 2.5-18.2]) and postoperative CSF leak (OR 3.5 [95% CI 1.4-8.5]). The preoperative SSI risk index, including body mass index, previous brain operation, chemotherapy on admission, preoperative LOS, procedure reason, and preoperative glucose level, had better predictive efficacy (c-statistic = 0.664) than the National Healthcare Safety Network risk index (c-statistic = 0.547; p = 0.004). Surgical site infections were associated with increased LOS during the initial hospitalizations (average increase of 50%) or readmissions (average increase of 100%) and with an increased risk of readmissions (OR 7.7 [95% CI 4.0-14.9]), reoperations (OR 36 [95% CI 14.9-87]), and death (OR 3.4 [95% CI 1.5-7.4]).

CONCLUSIONS

Surgeons were able to prospectively assess a patient's risk of SSI based on preoperative risk factors and they could modify some processes of care to lower the risk of SSI. Surgical site infections substantially worsened patients' outcomes. Preventing SSIs after CRANI could improve patient outcomes and decrease health care utilization.

Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors

BACKGROUND

To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs.

PROCEDURE

We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs.

RESULTS

We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17).

CONCLUSIONS

In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts.

Catheter related blood stream infections in the paediatric intensive care unit: A descriptive study

Context:

Catheter related blood stream infections (CRBSI) contributes significantly to morbidity, mortality and costs in intensive care unit (ICU). The patient profile, infrastructure and resources in ICU are different in the developing world as compared to western countries. Studies regarding CRBSI from pediatric intensive care unit (PICU) are scanty in the Indian literature.

Aims:

To determine the frequency and risk factors of CRBSI in children admitted to PICU.

Settings and Design:

Descriptive study done in the PICU of a tertiary care teaching hospital over a period of four months.

Materials and Methods:

Study children were followed up from the time of catheterization till discharge. Their clinical and treatment details were recorded and blood culture was done every 72 h, starting at 48 h after catheterization. The adherence of doctors to Centre for Disease Control (CDC) guidelines for catheter insertion was assessed using a checklist.

Statistical Analysis:

Clinical parameters were compared between colonized and non-colonized subjects and between patients with and without CRBSI. Unpaired t-test and Chi-square test were used to test the significance of observed differences.

Results:

Out of the 41 children, 21 developed colonization of their central venous catheter (66.24/1000 catheter days), and two developed CRBSI (6.3/1000 catheter days). Infants had a higher risk for developing colonization (P = 0.01). There was 85% adherence to CDC guidelines for catheter insertion.

Conclusions:

The incidence of CRBSI and catheter colonization is high in our in spite of good catheter insertion practices. Hence further studies to establish the role of adherence to catheter maintenance practices in reducing risk of CRBSI is required. The role of a composite package of interventions including insertion and maintenance bundles specifically targeting infants needs to be studied to bring down the catheter colonization as well as CRBSI rates.

Incidence, aetiology, and control of sternal surgical site infections

BACKGROUND

Since sternal surgical site infections (SSIs) can be life-threatening, every effort should be made to reduce their rate of occurrence.

AIM

To measure the rate of sternal SSIs after open heart surgery and to define the efficacy of infection control interventions in reducing this rate.

METHODS

Surveillance of sternal SSIs was carried out prospectively for adult patients who underwent sternotomy between 2005 and 2012. Infection control interventions that were undertaken during the study period at different time intervals were prophylaxis with cefazolin or vancomycin, surveillance of sternal SSIs and feedback, preoperative nasal Staphylococcus aureus screening and decolonization with mupirocin, isolation of patients infected with or colonized by meticillin-resistant S. aureus, appropriate management of perioperative blood glucose level and chlorhexidine/alcohol usage for skin antisepsis.

FINDINGS

There were 479 sternal SSIs in 18,460 patients during the study period (2.59%). The most frequent causes of sternal SSIs were coagulase-negative staphylococci (CoNS) (36%) and S. aureus (31%). Infection control interventions reduced the rate of sternal SSIs from 3.63% in 2005 to 1.65% in 2012 (P < 0.0001).

CONCLUSION

Our study shows that the rate of sternal SSIs can be decreased with proper infection control interventions. However, the interventions that were undertaken were effective only in reducing the rate of sternal SSIs caused by S. aureus. It is time to find interventions to control sternal SSIs caused by CoNS, the pathogen responsible for most sternal SSIs in hospitals where S. aureus SSIs are successfully controlled.

Randomized controlled trial to reduce bacterial colonization of surgical drains after breast and axillary operations

OBJECTIVE

To determine whether bacterial colonization of drains can be reduced by local antiseptic interventions.

BACKGROUND

Drains are a potential source of bacterial entry into surgical wounds and may contribute to surgical site infection after breast surgery.

METHODS

After institutional review board approval, patients undergoing total mastectomy and/or axillary lymph node dissection were randomized to standard drain care (control) or drain antisepsis (treated). Standard drain care comprised twice daily cleansing with alcohol swabs. Antisepsis drain care included (1) a chlorhexidine disc at the drain exit site and (2) irrigation of the drain bulb twice daily with dilute sodium hypochlorite (Dakin's) solution. Culture results of drain fluid and tubing were compared between control and antisepsis groups.

RESULTS

Overall, 100 patients with 125 drains completed the study with 48 patients (58 drains) in the control group and 52 patients (67 drains) in the antisepsis group. Cultures of drain bulb fluid at 1 week were positive (1+ or greater growth) in 66% (38/58) of control drains compared with 21% (14/67) of antisepsis drains (P = 0.0001). Drain tubing cultures demonstrated more than 50 colony-forming units in 19% (8/43) of control drains versus 0% (0/53) of treated drains (P = 0.004). Surgical site infection was diagnosed in 6 patients (6%)--5 patients in the control group and 1 patient in the antisepsis group (P = 0.06).

CONCLUSIONS

Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains. Based on these data, further study of drain antisepsis and its potential impact on surgical site infection rate is warranted (ClinicalTrials.gov Identifier: NCT01286168).

Incidence and risk factors of surgical site infection in general surgery in a developing country

PURPOSE

To investigate the incidence of surgical site infections (SSIs) according to risk factors, etiological agents, antimicrobial resistance rates of pathogens, and antimicrobial prophylaxis (AMP) in a developing country.

METHODS

Prospective surveillance of SSIs was carried out in general surgery (GS) units between May 2005 and April 2009.

RESULTS

SSI was diagnosed in 415 (10.8%) patients. Cefazolin was used as AMP in 780 (49%) operations, whereas broad-spectrum antibiotics were used in the remaining operations. AMP was administered for >24 h in 69 and 64% of the GS patients. The most significant risk factors for SSI after GS were total parenteral nutrition, transfusion, and a drainage catheter. The most common pathogen was Escherichia coli, but all the isolated pathogens were multiresistant.

CONCLUSION

AMP is effective for reducing the risk of SSI; however, the prolonged use of AMP and broad-spectrum antibiotics may be associated with the emergence of resistant bacterial strains.

Statewide costs of health care-associated infections: estimates for acute care hospitals in North Carolina

BACKGROUND

State-specific, health care-associated infection (HAI) cost estimates have not been calculated to guide Department of Public Health efforts and investments.

METHODS

We completed a cost identification study by conducting a survey of 117 acute care hospitals in NC to collect surveillance data on patient-days, device-days, and surgical procedures during 1 year. We then calculated expected rates and direct hospital costs of surgical site infections (SSI), Clostridium difficile infection, and 3 selected device-related HAIs for hospitals and the entire state using reference data sets such as the National Healthcare Safety Network.

RESULTS

In total, 67 (53%) hospitals responded to the survey. The median bed size of respondent hospitals was 140 (interquartile range, 66-350). A "standard" NC hospital diagnosed approximately 100 HAI each year with estimated costs of $985,000 to $2.7 million. The most common HAI was SSI (73%). Costs related to SSI accounted for 87% to 91% of overall costs. In total, the overall direct annual cost of these 5 selected HAIs was estimated to be between $124.1 and $347.8 million in 2009 for the state of NC.

CONCLUSION

Using conservative estimates, HAI led to costs of more than $100 million in acute care hospitals in the state of NC in 2009. The majority of costs were due to SSI.

Incidence of infectious complications associated with central venous catheters in pediatric population

BACKGROUND

Central venous catheters (CVC) are essential in intensive pediatric care units (PICU). Preventive measures during insertion and maintenance reduce infection risks.

METHODS

A prospective cohort study was conducted from January 2010 to December 2011 in a Brazilian university hospital PICU. Patients were followed throughout hospital stay to verify the occurrence of catheter-associated infection (CAI). An active search was performed of the daily prospective data related to the practice of CVC insertion.

RESULTS

There was a total of 255 catheter insertions with a CAI incidence density of 13.55/1,000 CVC-days. No association was found between an increased risk for infection and surgical hand antisepsis, the use of maximum barrier precautions, or the use of chlorhexidine for skin antisepsis, which were recommended for the prevention of CAIs. A multivariate analysis showed that catheter use for less than 7 days was protective (P < .01; odds ratio, 0.29; 95% confidence interval: 0.12-0.72).

CONCLUSION

Health care teams responsible for CVC insertion should rigorously assess the need for CVC and remove them within 7 days when possible. For patients who have no indication for CVC removal, monitoring with clinical evaluation and requests for additional blood cultures should be scrutinized rigorously.

Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated

BACKGROUND

Comatose patients present a high risk of early-onset ventilator-associated pneumonia (EO-VAP) for which antibiotic prophylaxis has been proposed. Comatose patients were studied to evaluate the efficacy of a single-dose of antibiotic prophylaxis at intubation against EO-VAP.

METHODS

A prospective cohort of comatose patients (Glasgow Coma Score ≤ 8) who were admitted in 2009-2010 and administered a single-dose of antibiotic within 4 h of intubation was compared with comatose patients (admitted ≥ 4 h after intubation in 2009-2010 or admitted in 2007-2008) who did not receive antibiotic prophylaxis. We analyzed the incidence of EO-VAP, late-onset VAP, and ventilator-associated tracheobronchitis in both groups. Propensity scores for receiving antibiotic prophylaxis were derived on the basis of patients' characteristics (eg, age and severity) to assess its impact on EO-VAP development.

RESULTS

We included 129 patients (71 in the prophylaxis group and 58 in the control group). The global incidence of VAP and incidence of EO-VAP were lower in the prophylaxis group: 10.8 vs 28.4 episodes/1,000 days on mechanical ventilation (P = .015) and 4.4 vs 23.1 episodes/1,000 days on mechanical ventilation (P = .02), respectively. The incidence of late-onset VAP did not differ. The prophylaxis group tended toward lower incidence of ventilator-associated tracheobronchitis (15.5% vs 25.9%, P = .14). No differences in mortality were found between groups. The propensity-score regression analysis confirmed that a single dose of antibiotic prophylaxis was independently associated with lower incidence of EO-VAP (OR, 0.11; 95% CI, 0.02-0.58; P = .009).

CONCLUSIONS

A single dose of antibiotic prophylaxis at intubation might lower the incidence of EO-VAP. However, a randomized clinical trial should be conducted to confirm our findings.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in persons who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions may reduce the risk of VAP in these patients.

OBJECTIVES

To assess the effects of OHC on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 14 January 2013), CENTRAL (The Cochrane Library 2012, Issue 12), MEDLINE (OVID) (1946 to 14 January 2013), EMBASE (OVID) (1980 to 14 January 2013), LILACS (BIREME) (1982 to 14 January 2013), CINAHL (EBSCO) (1980 to 14 January 2013), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013), OpenGrey and ClinicalTrials.gov (to 14 January 2013). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all search results, extracted data and undertook risk of bias. We contacted study authors for additional information. Trials with similar interventions and outcomes were pooled reporting odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes using random-effects models unless there were fewer than four studies.

MAIN RESULTS

Thirty-five RCTs (5374 participants) were included. Five trials (14%) were assessed at low risk of bias, 17 studies (49%) were at high risk of bias, and 13 studies (37%) were assessed at unclear risk of bias in at least one domain. There were four main comparisons: chlorhexidine (CHX mouthrinse or gel) versus placebo/usual care, toothbrushing versus no toothbrushing, powered versus manual toothbrushing and comparisons of oral care solutions.There is moderate quality evidence from 17 RCTs (2402 participants, two at high, 11 at unclear and four at low risk of bias) that CHX mouthrinse or gel, as part of OHC, compared to placebo or usual care is associated with a reduction in VAP (OR 0.60, 95% confidence intervals (CI) 0.47 to 0.77, P < 0.001, I(2) = 21%). This is equivalent to a number needed to treat (NNT) of 15 (95% CI 10 to 34) indicating that for every 15 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP will be prevented. There is no evidence of a difference between CHX and placebo/usual care in the outcomes of mortality (OR 1.10, 95% CI 0.87 to 1.38, P = 0.44, I(2) = 2%, 15 RCTs, moderate quality evidence), duration of mechanical ventilation (MD 0.09, 95% CI -0.84 to 1.01 days, P = 0.85, I(2) = 24%, six RCTs, moderate quality evidence), or duration of ICU stay (MD -0.21, 95% CI -1.48 to 1.89 days, P = 0.81, I(2) = 9%, six RCTs, moderate quality evidence). There was insufficient evidence to determine whether there is a difference between CHX and placebo/usual care in the outcomes of duration of use of systemic antibiotics, oral health indices, microbiological cultures, caregivers preferences or cost. Only three studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.From three trials of children aged from 0 to 15 years (342 participants, moderate quality evidence) there is no evidence of a difference between OHC with CHX and placebo for the outcomes of VAP (OR 1.07, 95% CI 0.65 to 1.77, P = 0.79, I(2) = 0%), or mortality (OR 0.73, 95% CI 0.41 to 1.30, P = 0.28, I(2) = 0%), and insufficient evidence to determine the effect on the outcomes of duration of ventilation, duration of ICU stay, use of systemic antibiotics, plaque index, microbiological cultures or adverse effects, in children.Based on four RCTs (828 participants, low quality evidence) there is no evidence of a difference between OHC including toothbrushing (± CHX) compared to OHC without toothbrushing (± CHX) for the outcome of VAP (OR 0.69, 95% CI 0.36 to 1.29, P = 0.24 , I(2) = 64%) and no evidence of a difference for mortality (OR 0.85, 95% CI 0.62 to 1.16, P = 0.31, I(2) = 0%, four RCTs, moderate quality evidence). There is insufficient evidence to determine whether there is a difference due to toothbrushing for the outcomes of duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, microbiological cultures, adverse effects, caregivers preferences or cost.Only one trial compared use of a powered toothbrush with a manual toothbrush providing insufficient evidence to determine the effect on any of the outcomes of this review.A range of other oral care solutions were compared. There is some weak evidence that povidone iodine mouthrinse is more effective than saline in reducing VAP (OR 0.35, 95% CI 0.19 to 0.65, P = 0.0009, I(2) = 53%) (two studies, 206 participants, high risk of bias). Due to the variation in comparisons and outcomes among the trials in this group there is insufficient evidence concerning the effects of other oral care solutions on the outcomes of this review.

AUTHORS' CONCLUSIONS

Effective OHC is important for ventilated patients in intensive care. OHC that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both CHX and toothbrushing is different from OHC with CHX alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP.

Reporting surgical site infections following total hip and knee arthroplasty: impact of limiting surveillance to the operative hospital

BACKGROUND

Public reporting of surgical site infections (SSIs) by hospitals is largely limited to infections detected during surgical hospitalizations or readmissions to the same facility. SSI rates may be underestimated if patients with SSIs are readmitted to other hospitals. We assessed the impact of readmissions to other facilities on hospitals' SSI rates following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

This was a retrospective cohort study of all patients who underwent primary THA or TKA at California hospitals between 1 January 2006 and 31 December 2009. SSIs were identified using ICD-9-CM diagnosis codes predictive of SSI assigned at any California hospital within 365 days of surgery using a statewide repository of hospital data that allowed tracking of patients between facilities. We used statewide data to estimate the fraction of each hospital's THA and TKA SSIs identified at the operative hospital versus other hospitals.

RESULTS

A total of 91 121 THA and 121 640 TKA procedures were identified. Based on diagnosis codes, SSIs developed following 2214 (2.3%) THAs and 2465 (2.0%) TKAs. Seventeen percent of SSIs would have been missed by operative hospital surveillance alone. The proportion of hospitals' SSIs detected at nonoperative hospitals ranged from 0% to 100%. Including SSIs detected at nonoperative hospitals resulted in better relative ranking for 61% of THA hospitals and 61% of TKA hospitals.

CONCLUSIONS

Limiting SSI surveillance to the operative hospital caused varying degrees of SSI underestimation and substantially impacted hospitals' relative rankings, suggesting that alternative methods for comprehensive postdischarge surveillance are needed for accurate benchmarking.

Public reporting of hospital-acquired infections is not associated with improved processes or outcomes

Most US states have enacted or are considering legislation mandating hospitals to publicly report hospital-acquired infection (HAI) rates. We conducted a survey of infection control professionals and found that state-legislated public reporting of HAIs is not associated with perceived improvements in infection prevention program process measures or HAI rates.

Multidrug-resistant bacterial isolates in infected wounds at Jimma University Specialized Hospital, Ethiopia

Background

The term ’Multidrug-resistant’ (MDR) applies to a bacterium that is simultaneously resistant to a number of antimicrobials belonging to different chemical classes. The effectiveness of currently available antmicrobial drugs is decreasing due to the increasing number of resistant strains causing infections so that available therapeutic options for such organisms are severely limited.

Objective

The aim of this study was to determine multidrug-resistance rate of bacterial isolates that caused wound infections.

Methods

A Hospital based cross-sectional study was conducted on 322 wound samples taken from consecutive patients seen at inpatient and outpatient department of Jimma University Specialized Hospital from June to December 2011. Swabs from surgical incisions, burns, abscess and traumatic wounds were collected aseptically using Levine’s technique. Bacteriological culture and examination was done following standard microbiological techniques. Multidrug-resistance test was performed by disk diffusion method against 10 classes of antimicrobials. The data was analyzed for descriptive statistics using SPSS version 16 and Microsoft Excel.

Results

The overall MDR among gram positive and gram negative bacterial isolates were (77%) and (59.3%) respectively. About, 86.2% S.aureus and 28.6% of Coagulase negative Staphylococci became MDR. Nearly 30.1% of S.aureus was resistant to six classes of antimicrobials. The average MDR rate of Proteus, Klebsiella, and Providencia species was 74.8%, 69.6% and 75% in that order. Nearly, 30.8% of Proteus sp, 32.6% of Klebsiella sp and 61% of Citrobacter sp were resistance to 4 classes each. Surprisingly, the average MDR rate for Citrobacter sp was 100%. About (76.7%) of S.aureus was Oxacillin/Methicillin resistant while (16.4%) were Vancomycin resistant. Proteus species was the predominant isolates (27.9%) followed by P.aeruginosa and S.aureus (19.3%) and (19%) respectively.

Conclusion

This study indicated that, the overall rate of MDR bacterial pathogens that caused wound infection was very high and many of the isolates were also identified as resistant to three or more classes of antimicrobials. Such widespread resistance to antimicrobial classes is something serious because a few treatment options remain for patients with wound infections. Periodic monitoring of etiology and antimicrobial susceptibility in areas where there is no culture facility is essential to assists physician in selection of chemotherapy.

Respiratory therapy device modifications to prevent ventilator-associated pneumonia

PURPOSE OF REVIEW

Ventilator-associated pneumonia (VAP) is a controversial entity in the field of critical care. After years of research and significant efforts from regulatory agencies and hospitals, this complication is still frequently affecting mechanically ventilated patients, making VAP an active battleground for research. As a result, several preventive measures have recently been tested in experimental and clinical trials. Our interest is focused on those innovations related to the endotracheal tube (ETT).

RECENT FINDINGS

Four ETT-related VAP causative mechanisms are reviewed, together with different associated potential solutions. Technologies such as the subglottic secretion drainage and the Mucus Slurper have been studied to eliminate subglottic secretion pooling. Novel designs for the cuff and the management of its pressure may avoid leakage. Antimicrobial coatings can prevent endoluminal biofilm formation, whereas using an ETT cleaning device may also be beneficial. Finally, preserving the tracheal ciliary function will keep our best physiologic protection active.

SUMMARY

VAP prevention strategies are a continuously evolving field. Being able to identify the most valuable ideas needs a deep understanding of the disease pathophysiology. The role of the ETT is crucial and there is need for our standards of care to improve. This may soon be possible with newer technologies becoming increasingly available to clinicians.

Body mass index and risk of surgical site infection following spine surgery: a meta-analysis

PURPOSE

Inconsistent results have been reported in the literature on the association between obesity, expressed as increased body mass index (BMI), and risk for surgical site infection (SSI) following spine surgery. The objective of this study was to review and quantify the association between increased BMI and risk of spinal SSI in adults.

METHODS

We performed a comprehensive search for relevant studies using PubMed, Embase, and references of published manuscripts. Study-specific risk measures were transformed into slope estimates and combined using the random effects meta-analysis model to establish the risk of SSI associated with every 5-unit increase in BMI.

RESULTS

Thirty-four articles underwent full-text review. Variations were noted among these studies in relation to SSI diagnosis criteria and BMI cut-off levels used to define obesity. Data from 12 retrospective studies were included in the analyses. Results showed that BMI was significantly positively associated with the risk of spinal SSI. Unadjusted risk estimates demonstrated that a 5-unit increase in BMI was associated with 13 % increased risk of SSI [Crude odds ratio (OR): 1.13; 95 % CI: 1.07-1.19, p < 0.0001]. Pooling of risk estimates adjusted for diabetes and other confounders resulted in a 21 % increase in risk of spinal SSI for every 5-unit increase in BMI (adjusted OR: 1.21; 95 % CI 1.13-1.29, p < 0.0001).

CONCLUSION

Higher BMI is associated with the increased risk of SSI following spine surgery. Prospective studies are needed to confirm this association and to determine whether other measures of fat distribution are better predictors of risk of SSI.

Visualizing Central Line -Associated Blood Stream Infection (CLABSI) Outcome Data for Decision Making by Health Care Consumers and Practitioners-An Evaluation Study

The purpose of this study was to evaluate information visualization of publicly-reported central line-associated blood stream infection (CLABSI) outcome data for decision making by diverse target audiences – health care consumers and practitioners. We describe the challenges in publicly reporting of healthcare-associated infections (HAIs) data and the interpretation of an evaluation metric. Several options for visualization of CLABSI data were designed and evaluated employing exploratory working group, two confirmatory focus groups’ observations, and experts’ committee validation of the final designs. Survey-data collection and evaluation criteria results, collected from the two focus groups, are presented and are used to develop the final recommendations for how to visualize publicly-reported CLABSI data from Maryland acute care hospitals. Both health care consumer and practitioner’s perspectives are highlighted and categorized based on the visualizations’ dimensions framework. Finally, a recommended format for visualizing CLABSI outcome data based on the evaluation study is summarized.

Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010

OBJECTIVE

 To report the results of a surveillance study on surgical site infections (SSIs) conducted by the International Nosocomial Infection Control Consortium (INICC).

DESIGN

 Cohort prospective multinational multicenter surveillance study.

SETTING

 Eighty-two hospitals of 66 cities in 30 countries (Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece, India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay, and Vietnam) from 4 continents (America, Asia, Africa, and Europe).

PATIENTS

 Patients undergoing surgical procedures (SPs) from January 2005 to December 2010.

METHODS

 Data were gathered and recorded from patients hospitalized in INICC member hospitals by using the methods and definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) for SSI. SPs were classified into 31 types according to International Classification of Diseases, Ninth Revision, criteria.

RESULTS

 We gathered data from 7,523 SSIs associated with 260,973 SPs. SSI rates were significantly higher for most SPs in INICC hospitals compared with CDC-NHSN data, including the rates of SSI after hip prosthesis (2.6% vs. 1.3%; relative risk [RR], 2.06 [95% confidence interval (CI), 1.8-2.4]; P < .001), coronary bypass with chest and donor incision (4.5% vs. 2.9%; RR, 1.52 [95% CI, 1.4-1.6]; [P < .001); abdominal hysterectomy (2.7% vs. 1.6%; RR, 1.66 [95% CI, 1.4-2.0]; P < .001); exploratory abdominal surgery (4.1% vs. 2.0%; RR, 2.05 [95% CI, 1.6-2.6]; P < .001); ventricular shunt, 12.9% vs. 5.6% (RR, 2.3 [95% CI, 1.9-2.6]; P < .001, and others.

CONCLUSIONS

 SSI rates were higher for most SPs in INICC hospitals compared with CDC-NHSN data.

The impact of a quality improvement intervention to reduce nosocomial infections in a PICU

OBJECTIVE

To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes.

DESIGN

Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up.

SETTING

A 14-bed medical and surgical PICU in a university hospital for children.

INTERVENTIONS

The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing nosocomial infections.

MEASUREMENTS AND MAIN RESULTS

We included 851 patients in the preintervention period, 822 in the intervention period, and 940 in the long-term follow-up period. Compared with the preintervention period, in the intervention period, the rates of central line-associated bloodstream infection decreased from 8.1 to 6/1,000 central venous catheter-days (p = 0.640), ventilator-associated pneumonia decreased from 28.3 to 10.6/1,000 days' ventilation (p = 0.005), and catheter-associated urinary tract infection decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). Multivariable logistic regression found that nosocomial infections was independently associated with increased mortality (odds ratio, 2.35 [95% CI, 1.02-5.55]; p = 0.046). Compared with the preintervention period, in the long-term follow-up period, central line-associated bloodstream infection decreased to 4.6/1,000 central venous catheter-days (p = 0.205); ventilator-associated pneumonia decreased to 9.1/1,000 ventilation-days (p = 0.001), and catheter-associated urinary tract infection decreased to 5.2/1,000 urinary catheter-days (p < 0.001). Hospital length of stay (14.45 days; p = 0.048) and mortality (3.2%; p = 0.058) also decreased.

CONCLUSIONS

A multifaceted quality improvement intervention reduced nosocomial infection rates, hospital length of stay, and mortality in our PICU. The effects of the intervention were sustained over time.

Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites

PURPOSE

To compare peripherally inserted central catheter (PICC) complication rates in upper versus lower extremity insertion sites in neonates.

SUBJECTS

Neonates who had PICCs inserted while hospitalized in an urban, 84-bed, level III neonatal intensive care unit in the southwestern United States between 2004 and 2009 were included in the study. A total of 559 neonates with 626 PICCs were reviewed. Neonates who were transferred out of the hospital with an indwelling PICC or had incomplete PICC data were excluded (n = 29).

DESIGN

Comparative descriptive.

METHOD

Retrospective review of PICC records. Demographic data, neonate survival to PICC removal, PICCs inserted by non-PICC team members, and complications were compiled. Complications included presumed sepsis, occlusion, leaking, infiltration/edema, inadvertent removal, phlebitis, pleural effusion, tip malposition, and catheter breakage. The complications were analyzed between extremities using chi-square or independent-samples t test where appropriate.

MAIN OUTCOME MEASURES

Type and rate of complication requiring PICC removal and the extremity used for insertion.

PRINCIPAL RESULTS

A total of 374 PICCs (59.7%) were inserted in upper extremities and 252 (40.3%) in lower extremities. The upper and lower extremity groups were comparable in all variables except neonate survival to PICC removal, which was greater in neonates with lower extremity PICCs (95.2% in upper extremities vs 98.8% in lower extremities; P = .01). No significant difference (P = .08) was found in the overall complication rate (27% in upper extremity PICCs vs 21% in lower extremity PICCs). Presumed sepsis was the most common complication requiring PICC removal in both extremity groups. At the time of removal, upper extremity PICCs were more likely to have a noncentral tip than lower extremity PICCs (15% vs 4%, respectively). In PICCs removed because of complications, noncentral tips were found to be statistically significant in upper extremity PICCs (P < .0001).

CONCLUSIONS

No significant difference was found in complications that necessitated PICC removal between upper versus lower extremity PICC insertion sites. Catheter tip location may have a significant impact on complications and deserves further investigation. The choice of a PICC insertion site in neonates should be based on the quality of appropriate, available veins and the preference and skill of the inserter. Every effort should be made to achieve and maintain a centrally located PICC tip.

Reducing central line infections in pediatric and neonatal patients

The stakes for the prevention of central line associated bloodstream infections (CLABSIs) have increased dramatically over the past decade. Over the past 10 years, the rate of CLABSI in the pediatric population has dropped markedly due to the significant investment in this initiative. Although there has been a substantial increase in studies on CLABSIs, difficulties in studying CLABSIs have limited the quality of the evidence produced. These difficulties include challenges in the sample size required to complete trials, pressure from external regulatory forces to reduce CLABSI rates, and challenges in defining CLABSIs. The definition of CLABSI is continuously being updated to improve the misclassification bias inherent in defining CLABSI. This is especially relevant given the stress placed on decreasing health-care-associated infections and the negative consequences associated if unsuccessful. In order to prevent CLABSIs, pediatric and neonatal intensive care units have formed bundles of basic evidenced-based strategies leading to effective reduction of CLABSIs. These basic bundles have been modified for spread to other nonintensive care areas, also yielding great results. However, additional therapies above the basic bundle have yielded mixed results, and more research is needed to understand the cost effectiveness of these therapies in the setting of decreasing CLABSI rates. As a goal, a "getting to zero" CLABSI rate should be set, but it may not be possible without significant resource allocation.

Management and prevention of ventilator-associated pneumonia caused by multidrug-resistant pathogens

Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphylococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antiimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.

Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage?

INTRODUCTION

The Joint Commission Surgical Care Improvement Project (SCIP) includes performance measures aimed at reducing surgical site infections (SSI). One measure defines approved perioperative antibiotics for general operative procedures. However, there may be a subset of procedures not adequately covered with the use of approved antibiotics. We hypothesized that piperacillin-tazobactam is a more appropriate perioperative antibiotic for pancreaticoduodenectomy (PD).

METHODS

In collaboration with hospital epidemiology and the Division of Infectious Diseases, we retrospectively reviewed records of 34 patients undergoing PD between March and May 2008 who received SCIP-approved perioperative antibiotics and calculated the SSI rate. After changing our perioperative antibiotic to piperacillin-tazobactam, we prospectively reviewed PDs performed between June 2008 and March 2009 and compared the SSI rates before and after the change.

RESULTS

For 34 patients from March through May 2008, the SSI rate for PD was 32.4 per 100 cases. Common organisms from wound cultures were Enterobacter and Enterococcus (50.0% and 41.7%, respectively), and these were cefoxitin resistant. From June 2008 through March 2009, 106 PDs were performed. During this period, the SSI rate was 6.6 per 100 surgeries, 80% lower than during March through May 2008 (relative risk, 0.204; 95% confidence interval [CI], 0.086-0.485; P = .0004).

CONCLUSION

Use of piperacillin-tazobactam as a perioperative antibiotic in PD may reduce SSI compared with the use of SCIP-approved antibiotics. Continued evaluation of SCIP performance measures in relationship to patient outcomes is integral to sustained quality improvement.

Efficacy of prophylactic antibiotic administration for breast cancer surgery in overweight or obese patients: research highlight

The rate of surgical site infection (SSI) after breast surgery is higher than expected for a 'clean procedure'. There is currently no consensus on the use of antibiotics, and as a result there is variation in use. An infection may compromise cosmesis and delay the start of adjuvant therapy. This research highlight reviews a recent paper by Gulluoglu and colleagues investigating the use of antibiotics in overweight and obese patients undergoing breast cancer surgery and also reviews the current literature on this important topic.

Preventing healthcare-associated infections: beyond best practice

The goal of this review is to evaluate best practices for preventing healthcare-associated infections (HAI) and to identify opportunities beyond best practice. Achieving an infection-free hospital stay for patients will require integration of infection prevention into routine bedside clinical care. The objectives are (1) to summarize the best practices for prevention of HAI; (2) to discuss the limitations of known best practices; and (3) to discuss potential approaches beyond best practice to prevent HAI. Rationale for comprehensive horizontal approaches with active caregiver participation is discussed.

Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia

BACKGROUND

Oral care may decrease ventilator-associated pneumonia in the ICU. The objective of this review was to summarize and critically appraise randomized trials in mechanically ventilated patients in the ICU testing the effect of oral care strategies involving toothbrushing on ventilator-associated pneumonia.

SEARCH METHODS

We searched EMBASE, MEDLINE, and the Cochrane Controlled Trials Register and Database of Systematic Reviews from 1980 until March 2012, independently and in duplicate, as well as personal files and reference lists. In duplicate, articles were selected if they were randomized trials, enrolled adult critically ill patients, compared any kind of oral care involving toothbrushing with any other kind of oral care or control with or without toothbrushing, and examined ventilator-associated pneumonia. In duplicate, we abstracted trial characteristics and quality using the Cochrane risk of bias tool. The results were combined using a random effects model.

RESULTS

We included six trials enrolling 1,408 patients, five of which compared toothbrushing to usual oral care and one of which compared electric with manual toothbrushing. In four trials, there was a trend toward lower ventilator-associated pneumonia rates (risk ratio, 0.77; 95% confidence interval, 0.50-1.21; p = 0.26). This trend was also observed in one trial reporting fewer cases of ventilator-associated pneumonia per 1,000 ventilator days (20.68 vs. 25.89; p = 0.53) in patients receiving toothbrushing vs. no toothbrushing. The only trial with low risk of bias suggested that toothbrushing significantly reduced ventilator-associated pneumonia (risk ratio, 0.26; 95% confidence interval, 0.10-0.67; p = 0.006). Use of chlorhexidine antisepsis seems to attenuate the effect of toothbrushing on ventilator-associated pneumonia (p for the interaction = 0.02). One trial comparing electric vs. manual toothbrushing showed no difference in ventilator-associated pneumonia rates (risk ratio, 0.96; 95% confidence interval, 0.47-1.96; p = 0.91). Toothbrushing did not impact on length of ICU stay, or ICU or hospital mortality.

CONCLUSIONS

In intubated, mechanically ventilated critically ill patients, toothbrushing did not significantly reduce the risk of ventilator-associated pneumonia overall. Toothbrushing has no effect on mortality or length of stay. Electric and manual toothbrushing seem to have similar effects. More research is needed on this aspect of oral care to evaluate its potential to decrease ventilator-associated pneumonia.

Can inpatient hospital experiences predict central line-associated bloodstream infections?

Background

Factors that increase the risk of central line-associated bloodstream infections (CLABSIs) are not fully understood. Recently, Hospital Compare began compiling data from hospital-required reporting to the CDC's National Healthcare Safety Network on CLABSIs in intensive care units (ICUs), at over 4,000 Medicare-certified hospitals in the United States, and made this data accessible on a central website. Also available on the same website are results from the Hospital Consumer Assessment of Healthcare Providers and Systems survey of patients' hospital experiences. Utilizing both databases, our objective was to determine whether patients' hospital experiences were significantly associated with increased risk for reported ICU CLABSI.

Methods and Findings

We conducted a zero-inflated Poisson regression analysis at the hospital level on CLABSI-observed cases by ICUs in acute care hospitals (n = 1987) in the United States between January 1, 2011, and December 31, 2011. During this period there were a total of 10,866 CLABSI cases and 9,543,765 central line days. In our final model, the percent of patients who reported that they “sometimes” or “never” received help as soon as they wanted was significantly associated with an increased risk for CLABSIs.

Conclusions

Using national datasets, we found that inpatients' hospital experiences were significantly associated with an increased risk of ICU reported CLABSIs. This study suggests that hospitals with lower staff responsiveness, perhaps because of an understaffing of nurse and supportive personnel, are at an increased risk for CLABSIs. This study bolsters the evidence that patient surveys may be a useful surrogate to predicting the incidence of hospital acquired conditions, including CLABSIs. Moreover, our study found that poor staff responsiveness may be indicative of greater hospital problems and generally poorly performing hospitals; and that this finding may be a symptom of hospitals with a multitude of problems, including patient safety problems, and not a direct cause.

Early nonbronchoscopic bronchoalveolar lavage: predictor of ventilator-associated pneumonia?

BACKGROUND

Ventilator-associated pneumonia is a problem in trauma and emergency general surgery patients. Our hospital-acquired infection prevention committee approved the use of early nonbronchoscopic bronchoalveolar lavage (screening-BAL) in the surgical intensive care unit (SICU) to identify ventilated patients with bronchiolar bacteria before 48 hours. We reviewed the results of this quality improvement initiative.

METHODS

All ventilated patients in the SICU (March 2011 to June 2012) underwent a screening-BAL 36 hours to 48 hours after intubation; quantitative culture results (>5 × 10(4) colony-forming unit per milliliter) were used to identify positive specimens. Clinical pneumonia was defined as clinical pulmonary infection score greater than 6 with a subsequent positive diagnostic-BAL result. Sequential organ failure assessment scores were averaged for the first 48 hours in the SICU. Continuous and dichotomous data were compared, and a multivariate regression analysis was performed on the screening-BAL and pneumonia results.

RESULTS

Screening-BALs were performed in 150 patients (99 trauma and 51 emergency general surgery patients), 72 of these specimens had positive findings. Fifty-three clinical pneumonias were diagnosed, and 45 (positive predictive value, 0.85) identified the same organism as the screening-BAL. Clinical pneumonia developed in eight patients with a negative screening-BAL (negative predictive value, 0.85). Antibiotic therapy at the time of the screening-BAL was associated with a negative screen (odds ratio, 0.44; p = 0.026). Pneumonia developed on median postintubation Day 4 (2-15 days) in patients with a positive screening-BAL results as compared with day 7.5 in the patients with a negative screening-BAL results (3.5-15 days; p = 0.007). Field intubation is an independent risk factor (odds ratio, 3.5; p = 0.004).

CONCLUSION

Positive screening-BAL results in trauma and emergency general surgery patients are associated with the development of ventilator-associated pneumonia by the same organism and may play a role in identifying patients at risk for pneumonia. Further studies must be conducted to evaluate the role of screening-BAL in this patient population.

LEVEL OF EVIDENCE

Diagnostic/prognostic study, level III.